Abstract
To reduce overcrowding in emergency departments (ED), which is a serious international problem, it is important to reduce the length of ED stay (ED LOS) of emergency patients. In particular, due to the COVID 19 pandemic, psychiatric emergency patients spent much longer in ED. This study was conducted to identify the characteristics of psychiatric emergency patients who visited the ED during the COVID-19 pandemic and to identify factors affecting ED LOS. This retrospective study was conducted on adult patients aged 19 years or older who visited a psychiatric emergency center operated by an ED from 1 May 2020 to 31 April 2021 because of the COVID-19 pandemic. In this study, the average ED LOS of psychiatric emergency patients was 7.8 h. Factors affecting ED LOS for over 12 h were isolation (OR = 2.39, CI = 1.409-4.052), unaccompanied police officers (OR = 2.106, CI = 1.338-3.316), night-time visits (OR = 2.127, CI = 1.357-3.332), use of sedatives (OR = 1.671, CI = 1.030-2.713), and restraints (OR = 1.968, CI = 1.172-4.895). The ED LOS of psychiatric emergency patients is longer than that of general emergency patients, and a long ED LOS causes ED overcrowding. To reduce the ED LOS of psychiatric emergency patients, they must be accompanied by a police officer when visiting the ED, and the treatment process should be reorganized so that a psychiatrist can promptly intervene. Furthermore, it is necessary to reorganize the isolation guidelines and admission criteria for mental emergency patients.
In particular, psychiatric emergency patients have a longer stay in the emergency department than general emergency patients.
In the context of the COVID-19 pandemic, factors affecting the length of stay in the emergency department by psychiatric emergency patients were presented.
It will be possible to reduce the length of stay in the emergency department by properly controlling the factors affecting the length of stay in the emergency department of psychiatric emergency patients.
Introduction
Since the outbreak of the COVID-19 pandemic, many countries have intermittently implemented lockdowns and other restrictions to reduce transmission rates and virus-related morbidity. As a result the number of patients with psychiatric disorders such as depression, anxiety, and post-traumatic stress has increased, which is causing overcrowding in ED. 1 ED overcrowding is defined as a situation in which the identified demand for emergency medical services exceeds the resources available to treat patients in the ED, the hospital, or both. 2 ED overcrowding is a serious international problem, 3 in emergency patient care, it can have negative effects, such as lowering patient satisfaction, delaying treatment, and worsening patient prognosis.4,5
Increased length of ED stay (ED LOS) leads to ED overcrowding, which has a negative impact on patient. 6 Therefore, it is important to cut the ED LOS in emergency patients to reduce ED overcrowding. Although ED LOS does not directly measure ED overpopulation, efforts are being made to reduce ED LOS in countries worldwide, as it is a valuable tool for monitoring the quality of ED care. 7 In the case of the UK, a policy of limiting ED LOS to 4 h has been in effect since 2004, 8 and in New Zealand, policy efforts were made to limit ED LOS to 6 h in 2009. 9 These efforts are the same as in Korea. According to the 2022 emergency medical institution evaluation guidebook, ED LOS of patients with severe disease is used as an important indicator to evaluate the efficiency of emergency medical institution operations, and ED LOS is selected as an index for determining institutional grades and number as an interlocking indicator. However, the standard for ED LOS evaluation of patients with severe disease was an average of 8 h in 2017 and 7 h in 2018, and since the evaluation in 2019, it has been lowered to less than 6 h by year, increasing the burden on emergency medical personnel working in the field. Furthermore, among emergency patients who visited the ED, the weighted ratio of emergency patients who stayed for over 12 h was measured to induce a reduction in ED LOS. 10
However, it is known that patients who visit the ED for psychiatric disorders have a significantly longer ED LOS than general emergency patients because of delay in treatment by a psychiatrist and hospitalization in a drunken state.11,12 Especially, the ED LOS for psychiatric emergency patients was significantly longer. A psychiatric emergency is defined by the American Psychiatric Association as “a situation in which immediate intervention is required because there is a risk of harming oneself or others as an acute disorder in thinking, behavior, mood, and social relationships.” 13 In these psychiatric emergency patients, ED LOS was found to increase even when restraints were applied, or sedatives were used 14 and when the police did not visit together. 15
In Korea, before the COVID-19 pandemic in March 2020, emergency hospitalization of psychiatric emergency patients was possible at national psychiatric and public general hospitals. However, as these national and public hospitals have been changed to hospitals dedicated to treating COVID-19 confirmed patients, the number of medical institutions that can be hospitalized for psychiatric emergency patients who are not confirmed to have COVID-19 and who are highly likely to harm themselves or others has decreased, 16 and it is presumed that ED LOS increased because of this.
Therefore, in this study, the characteristics of psychiatric emergency patients who visited the ED during the COVID-19 pandemic and the factors affecting ED LOS were identified to suggest a way to overcome ED overcrowding.
Methods
Research Design
This retrospective study attempted to identify the factors affecting ED LOS and the characteristics of patients who visited the psychiatric emergency center of one ED in a psychiatric emergency that required immediate intervention because there was a risk of harm to themselves or others.
Study Subject
The subjects of this study were all adult patients 19 years of age or older who visited the psychiatric emergency center operating in 1 ED 1 May, 2020 to 31 April, 2021, which is the COVID-19 pandemic situation, as a psychiatric emergency. The specific selection criteria were as follows:
Selection criteria
A psychiatric emergency patient who visited the ED with police officers for fear of harming themselves or others.
A psychiatric emergency patient who visits the ED using a public ambulance or police car while harming themselves or others.
A psychiatric emergency patient was referred to the Department of Mental Health under the judgment of an emergency physician because of the risk of harm to themselves or others.
For patients who visited the hospital more than twice, only the records of the first visit were collected, and if EMR data necessary for statistical analysis were insufficient, they were excluded from the study.
Ethical Considerations
This study was conducted after being approved by the Clinical Research Review Committee of the hospital to which the researcher belongs. Written informed consent was not necessary because no patient data has been included in the manuscript. The Helsinki Declaration (revised in 2013) and the International Conference on Harmonization Good Clinical Practice guidelines (ICH-GCP) were complied with, and the collected medical record data were conducted scientifically and ethically in accordance with management standards and related laws. The electronic medical record data were received from the person in charge of the institution to which the researcher belongs, with the contents that could identify the patient’s personal information deleted, and the medical record data were kept as a separate file under the responsibility of the researcher. The collected data will be encrypted and stored in a separate locking device for 3 years.
Data Collection Procedure
The hospital where this researcher works operates a psychiatric emergency center, and psychiatric specialists are stationed there. Therefore, to collect the electronic medical record data required for this study, we identified the patients who met the study subject selection criteria. To this end, first, the medical record manager of the EMR operation team requested details of the patients who were referred to the Department of Psychiatry among those who visited the ED during the study period, and 1187 patients were delivered in the form of an Excel file. This file contains the date and time of admission, including age, gender, means of visit, route of visit, motive, disease status, companionship, police presence, hospital bed, main symptoms, history, initial state of consciousness, intoxication, ED LOS, and triage results. Names and social security numbers that could identify the patients’ personal information were not included. Next, by checking the electronic medical records of all patients, 728 patients who were judged to have acute disorders in thinking, behavior, mood, and social relationships that could harm themselves or others and require immediate intervention were selected. Next, patients who had consulted in other departments besides psychiatry were excluded. In addition, by referring to the evaluation criteria of domestic emergency medical institutions, the top 0.5% of ED LOS patients (36 patients) were excluded in consideration of specific long-term occupancy patients, such as patients requiring an infection isolation ward. Finally, data from 684 patients were collected, except for 8 patients who had insufficient or missing EMR data for statistical analysis.
Data Analysis
The collected data were analyzed using IBM SPSS Statistics (version 25.0; IBM Inc., Armonk, New York, USA), and the statistical significance of all the analyses and models used in this study was based on a P-value of less than .05. The detailed analysis method is as follows:
1) The general characteristics of the study subjects were calculated using descriptive statistics, and the nominal variables were frequency and percentage, while continuous variables were presented as mean and standard deviation.
2) To compare ED LOS according to general characteristics, the mean and standard deviation were presented using a student t-test.
3) To identify the factors that affect the LOS, which is the evaluation criterion of the patient’s stay index for emergency medical institution evaluation exceeding 12 h, binary logistic regression analysis was used to present the factors that had a statistically significant effect.
Results
General Characteristics of Psychiatric Emergency Patients Visiting the ED
Table 1 presents the general characteristics of the study participants. First, the average ED LOS was 469.04 min (±326.390), and the male to female ratio was high, and the average age was 36.78 (±15.541). ED LOS of less than 12 h and more than 12 h were found in 514 (75.1%) and 170 (24.9%) patients, respectively. The number of patients who visited during the day and night was 204 (29.8%) and 480 (70.2%), respectively. Additionally, the number of cases accompanied by police officers and those without police officers was 237 (34.6%) and 447 (65.4%), respectively, indicating that the number of cases without a police officer was higher, and 574 (83.9%) cases of medical insurance and 110 (16.1%) cases of medical protection were found.
General Characteristics of Psychiatric Emergency Patients Visiting the Emergency Department. N = 684.
SD = standard deviation; ED = emergency department; Etc. = etc et cetera.
ED LOS Comparison According to General Characteristics
Looking at the difference in ED LOS according to general characteristics, the average ED LOS of men and women was 516.93 min (±346.851) and 439.49 min (±309.842), respectively, and there was a statistically significant difference (P = .003), and significant differences were also observed in disease and injury at 504.65 min (±341.244) and 448.40 min (±316.029), respectively (P = .033). In the case of using the isolation room of the ED at the time of admission, it was 649.65 min (±357.494) and 443.75 min (±313.920), respectively, with and without the isolation room, and when the isolation room was used, the ED LOS was significantly longer (P = .001). Moreover, the ED LOS was shorter in the case with a companion at the time of visit (445.78 min ±314.645) than the case without (507.20 min ±341.999) (P = .019) and ED LOS was shorter in the case of a daytime visit (393.50 min ±316.946) compared to the case of a night-time visit (501.14 min ±325.368) (P = .001). ED LOS was higher with sedatives (589.00 min ±354.836) or with body restraints applied (644.66 min ±356.954) compared with no sedatives (417.34 min ±299.218) and no restraints (430.15 min ±306.217) long (P = .001, .001, respectively) and the ED LOS was longer in emergency hospitalization (632.06 min ±382.914) compared to the case without it (430.78 min ±299.427) (P = .001). Also, the ED LOS was shorter in the case with medical insurance (454.64 min ±319.236) than those without medical insurance or medical protection (544.19 min ±353.549) (P = .008) (Table 2).
Comparison of Length of ED Stay According to General Characteristics. N = 684.
SD = standard deviation; ED = emergency department.
Factors Affecting ED LOS of ≥12 h, Which is the Criterion for Evaluating the Patient Index for Staying in the Evaluation of Emergency Medical Institutions
Table 3 shows factors affecting ED LOS over 12 h. Binary logistic regression analysis was performed by setting whether ED LOS exceeded 12 h as a dependent variable, and by setting significant variables in general characteristics and variables significantly reported in earlier studies as independent variables. First, with Nagelkerke R 2 = 19.0 and Hosmer and Lemeshow test: X 2 = 8.355 (P = .400), the regression model was appropriate. When assigned to an isolation room at the time of admission, the probability of ED LOS exceeding 12 h was 2.39 times higher than when assigned to a general area (P = .001). Higher (P = .001). Also, when visiting the hospital at night, the probability of ED LOS exceeding 12 h was 2.127 times higher than that of daytime (P = .001), and when sedatives or restraints were applied, 1.671 and 1.968 times higher, respectively, compared to those who did not (P = .038, .010, respectively).
Factors Affecting the Length of ED Stay Longer Than 12 h.
OR = odds ratio; CI = confidence interval.
Discussion
In this study, the average ED LOS of psychiatric emergency patients was 7.8 h. In the ED, LOS management is a key factor. Especially, the ED LOS of patients in psychiatric emergencies is longer than that of general emergency patients because of the delay in treatment by psychiatric specialists 11 and the use of restraints or sedatives for patients in psychiatric emergencies. 14 Furthermore, in the case of a psychiatric emergency with a substantial risk of self-harm in a pandemic situation of infectious diseases, such as the current COVID-19 pandemic situation, the number of specialized medical institutions that can be hospitalized decreases, 16 so the ED LOS may be longer. The results of this study showed that 12 h-ED LOS was affected by whether or not to enter the isolation room, accompany the police, visit during irregular hours, administer sedatives or apply restraints, and be hospitalized. By properly controlling ED LOS, it will be possible to efficiently use emergency medical resources to prevent ED overcrowding. 6 Therefore, this discussion is about ways to reduce ED LOS, which can reduce ED overcrowding.
First of all, the average ED LOS of psychiatric emergency patients in this study was 19.5 h. These results are similar to the average of 24 h in a study 17 conducted at a tertiary hospital located in Bangkok, Thailand. However, in a study 18 conducted at Calary Hospital, Alberta, Canada, the average ED LOS was as low as 14 h. It is believed that this difference in ED LOS was partly due to the difference in the time when the study was conducted. This study and the study of Thumtecho et al 17 were conducted in the context of the COVID-19 pandemic, and the study of Lane et al 18 collected data in April 2014 and March 2018.
A significant difference was found in the time spent in the ED depending on whether the patient entered the isolation room at the time of admission. These results are related to the COVID-19 lockdown result of ED LOS confirmation of psychiatric patients for 6 months in the COVID-19 situation. It is like the result that appeared significantly longer than before. 19 When visiting the ED during a pandemic, all patients are checked for fever or respiratory symptoms, and if they had fever or respiratory symptoms, they were asked to be treated in an isolation room until real time reverse transcription-polymerase chain reaction (real time RT-PCR) test is reported negative. Furthermore, a real-time PCR negative test result sheet was requested by a specialized medical institution for these psychiatric emergency patients. We speculate that this screening process may have lengthened ED LOS. COVID-19, the current epidemic, even if the pandemic situation is over, a pandemic situation in which another infectious disease is prevalent may be recreated. During an infectious disease pandemic, most medical resources are focused on preventing the spread of infectious diseases and intensively treating patients with confirmed infections. Therefore, the problems of the existing weak treatment system for psychiatric emergency patients can get even bigger. To improve this, it is necessary to reorganize the quarantine guidelines for psychiatric emergency patients in the ED or the admission criteria for the isolation room.
In Korea, when a psychiatric emergency patient who harms himself or others occurs, a system is in place so that when someone reports to the public ambulance, the police are also reported at the same time. In this study, in the case of psychiatric emergency patients, if they did not come with the police at the time of their visit, they were more than twice as likely to have an ED LOS of over 12 h compared to those who came with the police. A study comparing 20 patients who came with the police shows they were younger than those who did not have violent tendencies, and alcohol, or drugs are often used. Nevertheless, the results of the ED LOS appearing shorter in patients visiting the police are like the results of this study. According to the Domestic Mental Health Welfare Act, police officers are not at a risk of harming themselves or others. It stipulates that in the case of psychiatric emergency patients who have a psychiatric emergency, they are obliged to transfer them to an emergency medical institution and refer them to emergency hospitalization. 21 However, police officers at the scene often hand over patients and return them to police stations. Police play an important role in the occurrence of mental emergencies in the community. In the United States, one police officer handles 6 mentally ill individuals per month. 22 The safety of patients and medical staff can also be ensured by clarifying the duties and scope of duties of the police for psychiatric emergency patients so that police officers accompany them to the ED. It is thought to be able to reduce ED LOS.
Because of this study, it was found that the ED LOS was longer in the case of psychiatric emergency patients visiting the ED at night compared to those visiting the ED during the day. These results are like the results that the ED LOS was longer at night than during the day because of checking the difference by time of the ED visit among psychiatric emergency patients who attempted suicide by poisoning among psychiatric emergency patients. 23 It is believed that the reason for the prolonged ED LOS of patients visiting at night is that emergency medical resources available at night are limited, and that, if power is needed, specialized medical institutions that can accommodate most mentally ill patients can be accommodated in the daytime.
In psychiatric emergencies, physical inhibition 24 or chemical inhibition 25 is recommended to prevent patients from harming themselves or others. In this study, the probability of ED LOS exceeding 12 h was more than 1.5 times higher in psychiatric emergency patients taking sedatives or applying restraints. Psychiatric emergency patients who inevitably need to administer sedative drugs or use restraints due to violence or risk of self-injury may have affected the increase in ED LOS. In addition, it is presumed that ED LOS may have increased due to the decrease in consciousness caused by the administration of sedatives, which delayed the consultation with a psychiatrist. Moreover, even when the restraint band was applied, it would not have been easy to meet a psychiatrist immediately because of the low compliance of the patient, and it is presumed that the ED LOS increased as a result. Before deciding whether to administer sedatives or apply restraints, it will be possible to reduce ED LOS if a decision is made on whether to receive emergency hospitalization through prompt intervention by a psychiatrist.
In this study, when emergency hospitalization was required, the likelihood of ED LOS exceeding 12 h was 3 times higher than that of non-essential hospitalization. According to Article 26 of the Domestic Mental Health Act, a person who is presumed to be mentally ill and who finds a patient at high risk of harming himself or others is very urgent, so he/she may be admitted voluntarily, hospitalized by a guardian, or hospitalized by mayor of city or county. If it is not possible to do so, it is stipulated that emergency hospitalization may be referred to a psychiatric institution with the consent of a psychiatrist and a police officer. 21 In a study 26 that analyzed the characteristics and risk factors of hospitalized emergency patients according to Article 26 of the Mental Health Act, 26 it was found that the average ED LOS was shorter in the case of emergency hospitalization than in the case of emergency hospitalization. These results contradict the findings of the present study. However, in this study, the proportion of patients with ED LOS within 24 h was only approximately 25%. This is thought to be related to approximately 40% of the cases without a guardian.
Our study showed a much higher likelihood of ED LOS of over 12 h in emergency hospitalization because of COVID-19. In a pandemic, national and public hospitals are suffering from COVID-19, which has been converted into dedicated hospitals and operated, and the number of specialized medical institutions that can accommodate psychiatric emergency patients has decreased. Additionally, all patients, including those in psychiatric emergency, are real-time RT PCR since a negative test result sheet is required, it is presumed that the ED LOS was prolonged because the ED had to wait for the test result to be reported.
Limitations
To the best of our knowledge, this study has several limitations, although it is the only study to identify factors affecting the ED LOS of psychiatric emergency patients during the COVID-19 pandemic. First, because data were collected only in the COVID-19 situation in this study, a comparative analysis with situations other than COVID-19 was not possible. Second, sample size and power analysis could not be performed because the study subjects were selected for a limited period due to the nature of the retrospective research study. Finally, it is difficult to generalize the results of the study because it was conducted in one psychiatric emergency center.
Conclusion
ED LOS in psychiatric emergency patients is longer than that in general emergency patients, and a long ED LOS may cause ED overcrowding. ED overcrowding is a serious international problem that requires thorough management because it can have a negative impact on emergency patient care. To reduce the ED LOS of psychiatric emergency patients, it is necessary to accompany the police officer when visiting the ED and to arrange the treatment process so that a psychiatric specialist can promptly intervene. It is thought that ED LOS can be reduced in the current COVID-19 pandemic situation through the reorganization of quarantine guidelines or quarantine room entry standards in the ED for psychiatric emergency patients.
Footnotes
Acknowledgements
We express our deepest gratitude to the Director of the emergency department for allowing us to conduct this study.
Author Contributions
KL and KJ conceived and designed the study, KJ and JHS analyzed the data, and HK and KJ wrote the manuscript. GB and JHS recruited the study participants and collected the data. GB and CSJ were involved in the interpretation of the data and contributed to the manuscript preparation. CSJ and KL were involved in title selection, data analysis, and drafting of the manuscript and approved the final manuscript. All authors have read and approved the final version of the manuscript.
Availability of Data
The datasets generated and/or analyzed during the current study are not publicly available because all authors do not consent to disclosure but are available from the corresponding author on reasonable request.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethics Approval and Consent to Participate
This study was approved by the SMG-SNU Boramae Medical Center Institutional Review Board (IRB approval number: 30-2021-89). All methods were performed in accordance with the relevant guidelines and regulations.
Informed Consent
Not applicable. Written informed consent was not necessary because no patient data has been included in the manuscript.
Ethical Approval
This study was conducted after being approved by the Clinical Research Review Committee of Boramae Medical Center to which the researcher belongs (approval number: 30-2021-89).
